Abstract
Ulcerative colitis (UC) and Crohn's disease (CD) are chronic inflammatory disorders, which require long term treatment to achieve remission and to prevent relapses and cancer. While current therapies are effective in most cases, they can have rare but serious side effects and are often associated with high costs. On the other hand, early discontinuation of an effective treatment may lead to a quick relapse and to complications at the restart of therapy. Therefore it is essential to determine the optimal duration of maintenance therapy, but clear guidelines are missing. The most important questions when deciding whether to continue or withdraw therapy in quiescent UC and CD patients are the efficacy of the continuous treatment to maintain remission in the long term, the frequency and severity of side effects, and the chance of relapse after discontinuation of therapy. This review summarizes the current knowledge on these topics with respect to 5-aminosalicylates, thiopurines, methotrexate, and biological therapies and collects information regarding when and in which specific patient groups, in the absence of risk factors, can withdrawal of therapy be considered without a high risk of relapse. Additionally, the particular aspect of colorectal cancer prevention by current therapies will also be discussed.
Highlights
Inflammatory bowel diseases (IBD), such as ulcerative colitis (UC) and Crohn’s disease (CD), are chronic, immunemediated disorders of the gastrointestinal tract
The most important questions in this debate are the following: is the medication able to maintain remission when taken on a regular basis or does the effect wane after a certain period of time; how often and how serious are side effects; what happens if the medication is withdrawn; and which specific risk factors are associated with relapse? This review aims to answer these questions by focusing on available information and current opinions regarding the optimal duration of therapy in UC and CD and, with the help of risk factors, aims to collect data to determine a subgroup of patients who have a very low relapse rate and where the discontinuation of therapy may be possible
As there was no significant difference between the relapse rates of patients who were switched to placebo and who continued on sulphasalazine, the conclusion of the first study was that it is safe to stop sulphasalazine maintenance therapy in patients who are symptom-free for at least 12 months [9]
Summary
Inflammatory bowel diseases (IBD), such as ulcerative colitis (UC) and Crohn’s disease (CD), are chronic, immunemediated disorders of the gastrointestinal tract. As there was no significant difference between the relapse rates of patients who were switched to placebo and who continued on sulphasalazine, the conclusion of the first study was that it is safe to stop sulphasalazine maintenance therapy in patients who are symptom-free for at least 12 months [9]. As the relapse rates were four times higher in the placebo group, the authors of the second study concluded that salazopyrine maintenance therapy should be continued in UC patients on remission unless there are harmful side effects [10]. The relapse rates were similar in the two groups at the end of the 12-month period This outcome agreed with previous preliminary results from Dickinson and colleagues, who followed 28 UC patients in remission for 12 months and found that “on-demand” sulphasalazine therapy was effective as continuous treatment to prevent relapse [36].
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